CLM-2026-019519
Heritage Community Hospital, Emergency Medicine. Service 2025-10-26 at emergency room (POS 23). Received 2026-05-25.
Member
Resolved through the identity graph
- Member
- Bobby Payne
- Member ID
- UHC-54861-76
- Date of birth
- 1988-08-17
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-422550
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1588
- Coverage period
- 2021-10-01 to present
- Deductible
- $204.07 of $3,500.006%
- Out-of-pocket maximum
- $1,475.36 of $14,000.0011%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2102151364
- Network
- In network
- Rendering NPI
- 2102151364
- Location
- Tampa, FL · TIN 69-1549407
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,160.00 | $1,188.00 | — | — | DeniedCO29 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $151.00 | $83.05 | — | — | DeniedCO29 |
| Totals | $2,311.00 | $1,271.05 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-214631
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010817 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-10-26: OPTIONS-PPO (PPO), effective 2021-10-01. | |
| Timely filing | Fail | CO29 | Received 211 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Community Hospital (2102151364). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Community Hospital2025-10-26 09:48
Patient seen for pneumonia, unspecified organism.
- SystemSystem: Claims system2026-05-25 02:28
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-25 10:30
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-214631.pdf4 pages
Itemised statement totalling $2311.00 across 2 lines.
- Er reported_report_PA-214631.pdf3 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 211 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.